MAXIMUS Federal Services Medicare Health Plan Reconsideration Process Manual Medicare Managed Care Reconsideration Project

Transcription

1 MAXIMUS Federal Services Medicare Health Plan Reconsideration Process Manual Medicare Managed Care Reconsideration Project MAXIMUS Federal Services 3750 Monroe Ave. Ste. 702 Pittsford, New York (585)

2 MAXIMUS FEDERAL SERVICES CONTACT INFORMATION Address: Telephone: MAXIMUS Federal Services Medicare Managed Care Reconsideration Project 3750 Monroe Ave. Ste. 702 Pittsford, New York Main Number: Key Contacts: Cathleen F. MacInnes, MAXIMUS Federal Services, Project Director, Medicare Managed Care Reconsideration Project Assistant to Project Director, MAXIMUS Federal Services, Medicare Managed Care Reconsideration Project Grady Herendeen, MAXIMUS Federal Services, Business Systems Manager Janice Eidem, MAXIMUS Federal Services, QIC Lead Case Status Inquiries: Web site: Fax: Case Information Fax: (please only submit case specific information such as returns for Requests for Information): Project Web Site: * Do not submit confidential case specific information by . 1

3 TABLE OF CONTENTS Section Page 1. INTRODUCTION 6 2. DEFINITIONS Adjudicator Appeal Appeal Process De novo Review Evidence of Coverage Expedited Reconsideration Independent Review Entity (IRE) Local Coverage Decision (LCD) Medicare Advantage Organization Medicare Appeal System (MAS) Medicare Health Plan Organization Determination Reconsideration Reconsideration Determination Notice Reopening Request for Information (RI) Standard Claim Reconsideration Standard Service Reconsideration 9 3. WORKING WITH MAXIMUS Federal Services Sources of Information about MAXIMUS FEDERAL SERVICES IRE Reconsideration Set-Up of New Managed Care Organizations with MAXIMUS Federal Services Identifying and Changing Medicare Health Plan Point of Contact Seeking Information about Cases Suggestions and Complaints Holidays BACKGROUND IMPORTANT CONSIDERATIONS PRIOR TO DEVELOPING THE RECONSIDERATION CASE FILE FOR SUBMISSION TO MAXIMUS FEDERAL SERVICES Medicare Health Plan s Organization Determination Notice Requirements Medicare Health Plan Validation of Party, Representative and Eligible Appeal Non-Medicare Plan Services Reconsideration Priority Medicare Health Plan Responsibility to Conduct a Full Reconsideration Medicare Health Plan Reconsideration with Incomplete Evidence

4 5. SUBMITTING VALID RECONSIDERATION CASE FILES TO MAXIMUS FEDERAL SERVICES Cases That Must be Submitted to MAXIMUS Federal Services for Reconsideration Time Standards for Submission of Cases to MAXIMUS Federal Services Preparation and Submission of the New Case File to MAXIMUS Federal Services MAXIMUS FEDERAL SERVICES RECONSIDERATION PROCESS MAXIMUS Federal Services Case Processing Time Standards Administrative Case Intake Policies on Communication with Medicare Health Plan and Appellant During Case Processing Adjudicator Case Review Physician Review Requests to Medicare Health Plan for Additional Information Reconsideration Determination Notices Enrollee Requests for Case Files POST RECONSIDERATION DETERMINATION PROCESSING MAXIMUS Federal Services Monitoring of Medicare Health Plan Compliance with Overturned Determinations IRE Reopening Process Administrative Law Judge (ALJ) Process Medicare Appeals Council Process HEALTH PLAN DISMISSAL PROCESSING AND APPEALS Notice of Dismissal of Appeal Request Dismissal Case File Requests MAXIMUS Review of Dismissal Decision Dismissal Case File Documentation Timeframes for MAXIMUS Federal Services Review Dismissal Review Decisions are Binding RECONSIDERATION DATA APPENDIX 9.1 Medicare Appeals System Medicare Health Plan Monitoring Reports Using the MAXIMUS Federal Services Website to Track Timeliness and Effectuation Reconsideration Case Forms and Instructions Instructions for Reconsideration Background Data Form and Case Narrative Reconsideration Background Data Form Instructions for Dismissal Case File Data Form Dismissal Case File Data Form Notice of Intent to Submit an Expedited Reconsideration Form New Case Transmittal Cover Sheet Request for Information Response Cover Sheet Statement of Compliance Form Reopening Request Form Statement of Compliance Form- ALJ 3

5 LIST OF EXHIBITS Exhibit Title Page 3-1 Medicare Managed Care & Pace Reconsideration Project Web Site Expedited Case Submission Timetable Explanation of "Case Material" Suggested Medical Records for Inpatient and Long-term Care Denials Suggested Medical Records for Other Common Types of Denials 30 4

6 MAXIMUS Federal Services MEDICARE HEALTH PLAN RECONSIDERATION PROCESS MANUAL MEDICARE MANAGED CARE RECONSIDERATION PROJECT Effective January

7 1. INTRODUCTION The Balanced Budget Act of 1997, as amended by Title II of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), requires the federal government to contract with an Independent Review Entity (IRE) to review and resolve coverage disputes between Medicare Advantage Organizations, Cost Plans and HCPPs (collectively referred to as Medicare Health Plans), and Medicare managed care enrollees. The Centers for Medicare & Medicaid Services (CMS) has contracted with the MAXIMUS Federal Services to serve as this independent entity. This manual contains the procedures for the coordination of Medicare Health Plans with MAXIMUS Federal Services in the processing of IRE level reconsiderations, and related postreconsideration activities. The IRE level reconsideration is one step in a larger multi-level Medicare Managed Care appeal process. For example, Medicare Health Plans are required to adhere to CMS policies for initial organization determinations and Medicare Health Plan level reconsiderations steps that occur well prior to the submission of a case file to MAXIMUS Federal Services. The focus of this manual is on the processes by which Medicare Health Plans and MAXIMUS Federal Services interrelate for the IRE level reconsideration. This manual is not intended to serve as a review of CMS policy governing Medicare Health Plan obligations for the appeal process overall. This manual presumes that the reader has a command of relevant Medicare policies such as: 42 CFR Part 422 Medicare Managed Care Manual Program Memorandum and Transmittals Certain policies, procedures and operational documents discussed in this manual are mandatory, and complete compliance by the Medicare Health Plan is expected. For such requirements, the term "must" or "mandatory" is used. In other areas we have attempted to provide the Medicare Health Plan with flexibility, but may have offered suggestions for work methods that we believe will enhance the working relationship between Medicare Health Plans and MAXIMUS Federal Services. In these areas, the term "recommended" or "suggested" or "optional" is used. Our hope is that the Medicare Health Plan user finds this manual clear and helpful. If you have suggestions or comments, please submit to: Cathleen F. MacInnes, Project Director Medicare Managed Care Reconsideration Project MAXIMUS Federal Services 3750 Monroe Avenue Ste. 702 Pittsford, New York Phone: Fax:

8 2. DEFINITIONS The following definitions are provided solely for use in this Manual. These definitions do not address all the significant terms used in 42 CFR Part 422, and in some instances paraphrase or summarize regulatory text. In the event of any discrepancy or inconsistency, the language of 42 CFR Part 422 supersedes these definitions. 2.1 ADJUDICATOR An appeal professional employed by MAXIMUS Federal Services to manage individual reconsideration case files. MAXIMUS Federal Services Adjudicators make coverage determinations. Adjudicators do not make medical necessity determinations. Medical necessity determinations are made by fully credentialed board certified physicians under contract with MAXIMUS Federal Services. 2.2 APPEAL A procedure to review a Medicare Health Plan's adverse organization determination that is contested by the enrollee or another authorized party. The term appeal applies to such procedures at any level of the multi-step Medicare Managed Care appeal process (for example, Medicare Health Plan reconsideration, IRE level reconsideration, ALJ hearing, and so on). 2.3 APPEAL PROCESS The entire multi-level Medicare managed care complaint process for addressing enrollee challenges to a Medicare managed care adverse organization determination. The IRE reconsideration process is one level in the broader Medicare managed care appeal process. 2.4 DE NOVO REVIEW A review of an individual dispute by a new and impartial reviewer. The new and impartial reviewer does not give preference to any previous determinations made on the individual dispute. 2.5 EVIDENCE OF COVERAGE This term describes the Medicare Health Plan document that sets forth the terms of coverage for the Medicare Health Plan enrollees. This document is sometimes called a Subscriber Contract or Subscriber Agreement. 2.6 EXPEDITED RECONSIDERATION A de novo review of an adverse organization determination that must be processed quickly to avoid endangering the life or health of the enrollee or the enrollee's ability to regain maximum function. Generally, expedited reconsiderations must be completed as soon as is medically indicated, but not longer than 72 hours, with a possible extension of up to 14 calendar 7

9 days if the delay is in the enrollee's interest. (See 42 CFR ). Examples of cases that should be expedited include pre-service skilled nursing facility cases, pre-service acute inpatient care cases and cases in which a physician indicates that applying the standard timeframe for making a determination could seriously affect the life or health of the enrollee or the enrollee's ability to regain maximum function. The Medicare Health Plan has an obligation to determine if an appeal should be expedited, including responding to an enrollee or provider request for expedited determination. However, MAXIMUS Federal Services has the authority to expedite processing of an IRE reconsideration that was not expedited by the Medicare Health Plan. 2.7 INDEPENDENT REVIEW ENTITY (IRE) The entity under contract with CMS to perform reconsideration of denials upheld at the Medicare Health Plan level reconsideration. MAXIMUS Federal Services is the Independent Review Entity. 2.8 LOCAL COVERAGE DECISION (LCD) A document, identified as an LCD, published by a Medicare fee for service contractor with jurisdiction over fee for service claims in a defined area that specifies coverage or clinical criteria for fee for service claim reimbursement. 2.9 MEDICARE ADVANTAGE ORGANIZATION An entity that is under contract with CMS to provide Medicare benefits to Medicare beneficiaries. Medicare Advantage Organizations offer Medicare Advantage Plans such as HMOs, PSOs, PPOs, SNPs MSAs and private FFS plans and certain other programs and demonstration projects. The determination of whether an entity is subject to the MA appeals requirements is made by CMS, not MAXIMUS Federal Services MEDICARE APPEAL SYSTEM (MAS) Data system used by MAXIMUS Federal Services for collecting specific data elements from reconsideration cases and for creating specific reports for CMS MEDICARE HEALTH PLAN Term used in this Manual and in MAXIMUS Federal Services correspondence to refer to a MA Plan, Cost Plan and/or HCPP ORGANIZATION DETERMINATION A decision of the Medicare Health Plan, or a person acting on its behalf, to approve or deny a payment for a health care service or a request for provision of health care service made by, or on behalf of, a Medicare Health Plan enrollee. An organization determination concerns 8

10 benefits an enrollee is entitled to receive under the Medicare Health Plan, including: i) basic benefits; ii) mandatory and optional supplemental benefits; and iii) co-payments. An organization determination is the Medicare Health Plan's initial coverage determination. Medicare Health Plans must have procedures for making standard determinations and expedited determinations. Expedited determinations apply to cases in which applying standard determination procedures could seriously jeopardize the enrollee's life, health or ability to regain maximum function. (See 42 CFR ) RECONSIDERATION A review of an adverse organization determination. This term applies both to the Medicare Health Plan and IRE level appeal proceeding RECONSIDERATION DETERMINATION NOTICE Letter used to communicate MAXIMUS Federal Services' final decision in a reconsideration REOPENING A review of a completed IRE reconsideration determination undertaken at the sole discretion of the IRE for the purpose of addressing a potential error in the determination. (See 42 CFR ) REQUEST FOR INFORMATION (RI) A MAXIMUS Federal Services document submitted to the Medicare Health Plan requesting information from the Medicare Health Plan to correct a case file deficiency STANDARD CLAIM RECONSIDERATION Reconsiderations related solely to a denial of claim payment or reimbursement. Claim reconsiderations must be completed within 60 days of request receipt. Claim reconsiderations may not be expedited. May also be referred to as a retrospective appeal STANDARD SERVICE RECONSIDERATION Reconsiderations of denials of authorization for service(s) including continuing services, which do not meet the criteria for an expedited reconsideration. Standard service reconsiderations must be completed within 30 calendar days of the request receipt, subject to a possible 14-calendar day extension if in the enrollee's interest. May also be referred to as a preservice appeal. 9

11 3. WORKING WITH MAXIMUS FEDERAL SERVICES This Chapter explains the basic processes for communicating with MAXIMUS Federal Services, under the following headings: 3.1 Sources of Information about MAXIMUS Federal Services IRE Reconsideration 3.2 Set-up of New Managed Care Organizations with MAXIMUS Federal Services 3.3 Identifying and Changing Medicare Health Plan Points of Contact with MAXIMUS Federal Services 3.4 Seeking Information About Active Cases 3.5 Suggestions and Complaints Please note that MAXIMUS Federal Services is not authorized by CMS to guide or instruct Medicare Health Plans on interpretation of CMS coverage policies, or matters related to Medicare Health Plan compliance with CMS appeals process requirements. For example, we are not able to offer Medicare Health Plans advice on how a hypothetical case would be decided if presented to us. Policy inquiries of this type should be directed by the Medicare Health Plan to its designated CMS Regional Office Account Manager. 3.1 SOURCES OF INFORMATION ABOUT MAXIMUS FEDERAL SERVICES IRE RECONSIDERATION Medicare Managed Care & PACE Reconsideration Project Process Manuals MAXIMUS Federal Services makes available process manuals for the Medicare Managed Care & PACE Reconsideration Project as the primary print source for information about the IRE program. MAXIMUS Federal Services makes available on its web site two manuals: one manual for Medicare Advantage plans and one manual for PACE Organizations. Each Manual contains process information specific to the Health Plan type. Health plans are welcome to download the applicable manual from the Project web site, Medicare Managed Care & PACE Reconsideration Project Web Site In addition to the process manuals, the Project web site, (See Exhibit 3-1) contains the following information: Links to CMS web sites for statute, regulation and manuals related to Medicare Managed Care Reconsideration Current and past versions of the Project newsletter, Recon Notes Updated Project Organization and Contact information National, Regional and Medicare Health Plan level Reconsideration data Case Status Information 10

12 Exhibit 3-1 Medicare Managed Care & PACE Reconsideration Project Web Site Case status information on the Project web site is purposefully limited to protect enrollee and Medicare Health Plan confidentiality. The case can only be accessed by the "reconsideration case number" that is assigned by the Medicare Appeal System upon receipt of a case file from the Medicare Health Plan. A reconsideration case number has no logical relationship to Social Security Number, Medicare Number, or any other confidential information. The information that can be obtained by reconsideration case number is limited to: IRE Request received date IRE Appeal Priority (Expedited, Standard Service, Standard Claim) Plan Reported Recon Receipt Date (from the Reconsideration Background Data Form) IRE Corrected Recon Receipt Date (if different than the Plan Reported Recon Receipt Date) Plan Extension IRE Recon Decision (Uphold, Overturn, Partial Overturn, Withdrawn, Dismissed, or Pending) IRE Reopen Decision (if applicable) ALJ Decision (if applicable) Last Decision Date Project Newsletter ("Recon Notes") MAXIMUS Federal Services publishes a newsletter, "Reconsideration Notes," which addresses commonly observed situations in the reconsideration process and updates 11

13 MAXIMUS Federal Services policies and procedures as needed. This newsletter is available to health plans and the public through our web site: SET-UP OF NEW MANAGED CARE ORGANIZATIONS WITH MAXIMUS FEDERAL SERVICES An entity that has established a new Medicare Advantage contract with CMS is encouraged to contact MAXIMUS Federal Services prior to its first enrollment effective date. Call or write the MAXIMUS Federal Services Project Director (See Manual Page ii, MAXIMUS Federal Services Contact Information). MAXIMUS Federal Services will arrange to provide the new Medicare Health Plan a telephonic briefing on the IRE project. 3.3 IDENTIFYING AND CHANGING MEDICARE HEALTH PLAN POINT OF CONTACT MEDICARE HEALTH PLAN KEY ORGANIZATION CONTACT As part of new Medicare Health Plan project set-up, MAXIMUS Federal Services requests that each Medicare Health Plan designate and maintain one key organization contact. Medicare Health Plans that operate under multiple CMS contract numbers must designate and maintain a Key Contact for each CMS contract. The Medicare Health Plan may use the same, or different, personnel as the Key Contact for each contract. This individual will be the official management contact with MAXIMUS Federal Services. MAXIMUS Federal Services will send the Key Contact all important materials. We will also contact this individual if we encounter a general issue working with the Medicare Health Plan, or an unusual and significant case-specific problem. The Medicare Health Plan should use the Key Contact to initiate contact with MAXIMUS Federal Services to resolve problems perceived by the Medicare Health Plan. To identify or change this individual, submit the Notice of Change in Key Organization Contact (located in Appendix) to MAXIMUS Federal Services via our project box at medicareappeal@maximus.com MEDICARE HEALTH PLAN INDIVIDUAL RECONSIDERATION CASE CONTACTS The Medicare Health Plan must designate a contact person on a Reconsideration Background Data Form submitted with each reconsideration case (See Appendix). The Medicare Health Plan may, but is not required to, use its Key Contact as the designated case specific contact. The Medicare Health Plan may vary the Case Contact from case to case. 3.4 SEEKING INFORMATION ABOUT CASES As discussed above, the Medicare Health Plan can obtain basic information concerning the status of active and decided cases via the Project web site, In addition, MAXIMUS Federal Services maintains a staffed switchboard Monday to Friday, from 8 AM to 5:30 PM and Saturday from 9 AM to 2 PM, Eastern Time (

14 3300). For calls made after normal business hours, you may choose to leave a message that will be returned the next business day or you can contact us via at medicareappeal@maximus.com. For inquiries simply about the processing status of a specific case file, or group of cases, please visit our website MAXIMUS Federal Services employs a staff of "Adjudicators" who manage individual reconsideration case files. Specific questions about a case under review should be directed to the individual Adjudicator assigned to the case in question. Consult MAXIMUS Federal Services case documentation, or ask the MAXIMUS Federal Services operator, to identify the Adjudicator assigned to the case. Information that is to be made part of the case file and used in the final determination must be submitted in writing. Medicare Health Plans are responsible for supporting its enrollees in the reconsideration process. Plans should not direct members to MAXIMUS Federal Services for routine case status inquiries. Medicare managed care enrollees may be referred to MEDICARE for general information regarding the Medicare managed care appeals process and to locate resources for assistance in the appeals process. 3.5 SUGGESTIONS AND COMPLAINTS MAXIMUS Federal Services is an ISO 9001:2008 certified Independent Review Entity. As such, management requires a formal process for identification of opportunities for corrective and preventive action, or continuous improvement. Please freely provide any suggestions or complaints to any MAXIMUS Federal Services staff member who is interacting with you, or to the Project Director. If you are not completely satisfied, the MAXIMUS Federal Services QIC Lead would appreciate the opportunity to address your concern. 3.6 HOLIDAYS MAXIMUS Federal Services offices will be closed for the following holidays: Thanksgiving Day Christmas Day New Year's Day MAXIMUS Federal Services will still accept delivery of case files on those days. If you intend to submit a case for receipt by MAXIMUS Federal Services on one of the abovelisted days, you must contact MAXIMUS Federal Services via telephone ( ) at least 24 hours in advance to arrange for case file delivery. 13

15 4. BACKGROUND IMPORTANT CONSIDERATIONS PRIOR TO DEVELOPING THE RECONSIDERATION CASE FILE FOR SUBMISSION TO MAXIMUS FEDERAL SERVICES The responsibilities of the Medicare Health Plan related to adverse organization determination ("denials") and the Medicare Health Plan level reconsideration are defined by CMS in 42 CFR Part 422, Subpart M and Chapter 13 of the CMS Medicare Managed Care Manual. This MAXIMUS Federal Services Medicare Health Plan Reconsideration Process Manual is based on the presumption that the Medicare Health Plan understands and complies with these CMS policies, and is not an instruction guide for them. The purpose of this Chapter is to highlight certain aspects of Medicare Health Plan s organization determination and reconsideration processing that directly impact subsequent IRE reconsideration. The topics addressed are: 4.1 Medicare Health Plan s Organization Determination Notice Requirements 4.2 Medicare Health Plan Validation of Party, Representative and Eligible Appeal 4.3 Non-Medicare Plan Services 4.4 Reconsideration Priority 4.5 Medicare Health Plan Responsibility to Conduct a Full Medicare Health Plan Reconsideration 4.6 Medicare Health Plan Reconsideration with Incomplete Evidence 4.1 MEDICARE HEALTH PLAN S ORGANIZATION DETERMINATION NOTICE REQUIREMENTS The Medicare Health Plan is required, in most instances, to provide a written organization determination ("denial") notice to the enrollee or the enrollee's representative (See Section 4.2). If a denial is subsequently appealed to MAXIMUS Federal Services for IRE reconsideration, a copy of the denial notice and dates pertaining to Medicare Health Plan organization determination processing must be included within the case file. MAXIMUS Federal Services closely reviews the organization determination to define the denied service or claim subject to IRE reconsideration. In addition, we compare the type, format and content of the notice to CMS requirements and report "notice deficiencies" to CMS. Finally, MAXIMUS Federal Services abstracts and reports to CMS the dates of the initial request for service (or payment) versus organization determination, for purposes of monitoring Medicare Health Plan timeliness. CMS has developed the following standardized denial notices: NOTICE OF DENIAL OF MEDICAL COVERAGE (NDMC) This OMB-approved notice applies to prior authorization denials, adverse organization determinations including termination of medical services (excepting Inpatient discharge denials). 14

16 The Medicare Health Plan must issue a NDMC when it receives a request for a service and the Medicare Health Plan denies the request, in whole or part. However, CMS policy recognizes that some "denials" may occur in the context of provider discussions with enrollees about patient care options, and that in such discussions it may be difficult to ascertain whether or not the enrollee believes a denial has occurred at that instant. For example, if an enrollee is discussing two treatment options with a physician, the physician might recommend the second option. Whether such a recommendation is a "denial" of the first option depends upon the enrollee's response (that is, acceptance or rejection of the physician's recommendation). Further, the enrollee might not contest the physician's recommendation during the visit, but could contest it at a later date. Due to these unavoidable complications, CMS policy does not obligate Medicare Health Plan providers to issue an NDMC, but does obligate providers to inform enrollees of their right to obtain an NDMC from the Medicare Health Plan. The Medicare Health Plan must issue the NDMC if so requested by the enrollee. If the Medicare Health Plan makes the denial (for example, in response to a provider's request for prior authorization), the Medicare Health Plan must issue the NDMC. In summary, in many instances the circumstances of an initial organization determination will necessitate issuance of an NDMC by the Medicare Health Plan. If so, the NDMC must be included in a case file submitted for IRE reconsideration. If a valid exception to the NDMC issuance requirement exists, the Medicare Health Plan should document the exception in the IRE case file. CMS has issued a standard form for the NDMC. Medicare Health Plans may not deviate from the language of the CMS form. Please note that the OMB control number must be displayed on the notice NOTICE OF DENIAL OF PAYMENT (NDP) A Medicare Health Plan completes and issues this notice when it denies a request for payment of a service that was already received by the enrollee. While CMS does have an OMBapproved notice, CMS also permits Medicare Health Plans to use the Medicare Health Plan's existing electronic formats that generate Explanation of Benefits, as long as the back or a separate attachment contains the NDP information about appeal rights. A copy of the completed NDP must be included in the Medicare Health Plan reconsideration case file NOTICE OF MEDICARE NON-COVERAGE (NOMNC) This OMB-approved notice should be issued when the plan discontinues coverage for Skilled Nursing Facility (SNF) stays, Home Health services or CORF services. CMS has specific requirements with regard to time and manner of delivery of this notice. (See 42 CFR and CMS Medicare Managed Care Manual, Chapter 13). Telephone delivery of the notice is only permitted in limited circumstances, and there are specific 15

17 requirements with regard to the documentation of the telephone call. See CMS Medicare Managed Care Manual, Chapter 13. It is important to note that reduction of a service within the SNF, Home Health, or CORF setting that does not result in termination of skilled coverage does not require the use of the NOMNC. Medicare Health Plans should use the NDMC for this purpose. Also, please note that CMS does not require use of the NOMNC in denials based on exhaustion of benefits. For terminations based on the exhaustion of Medicare benefits, Medicare Health Plans should use the NDMC. 4.2 MEDICARE HEALTH PLAN VALIDATION OF PARTY, REPRESENTATIVE AND ELIGIBLE APPEAL Federal regulations provide that the following parties may request a reconsideration of an organization determination: An enrollee (including his or her representative) An assignee of the enrollee (that is, a non-contract physician or other non-contract provider who has furnished a service to the enrollee and formally agrees to waive any right to payment from the enrollee for that service) The legal representative of a deceased enrollee's estate Any other provider or entity (other than the Medicare Health Plan) determined to have an appealable interest in the proceeding. (See 42 CFR ) It is a straightforward validation of the appealing party when the enrollee initiates the reconsideration request. It is not as straightforward to validate the appealing party when the Reconsideration request is made by a person other than the enrollee. Special considerations with respect to reconsideration requests made by persons other than the enrollee are discussed under the following sub-headings: Representative Documentation Provider-as-Party Documentation Provider as Person "Supporting" the Enrollee Appeal Representative of Deceased Enrollee s Estate Processing Reconsiderations with an Invalid Appeal Requestor Medicare Health Plans should carefully note that until an "authorized" representative or provider-as-party is formally validated and documented, the appeal process, including the Medicare Health Plan reconsideration, should not begin. In other words, if the Medicare Health Plan receives an appeal request from a representative who is not validated (See Section 4.2.1) the Medicare Health Plan should not initiate the Medicare Health Plan reconsideration process. The procedures in Section below instruct the Medicare Health Plan on proper technique for addressing Medicare Health Plan reconsideration requests submitted by non validated representatives or providers-as-party. 16

18 4.2.1 REPRESENTATIVE DOCUMENTATION It is the responsibility of the Medicare Health Plan, not MAXIMUS Federal Services, to correctly identify and apply the laws and procedures related to representation. An enrollee may designate any person as their representative. CMS in general requires that Medicare Health Plans document proof of the validity of the enrollee's representative. Special rules apply to two circumstances: (1) enrollees who are incapacitated and (2) providers as representatives. General Requirements If the party requesting the reconsideration is not the enrollee, and the special circumstances discussed below do not apply, it is the responsibility of the Medicare Health Plan to determine and document that the requesting party is an appropriate representative of the enrollee. (See CMS Medicare Managed Care Manual, Chapter 13). Appropriate documentation may include, but is not limited to, a durable power of attorney, a health care proxy, an appointment of guardianship or other legally recognized forms of appointment. In the event the Medicare Health Plan does not have access to these documents, an Appointment of Representative form accepted by MAXIMUS Federal Services for this purpose is included in the Appendix of the Medicare Managed Care Manual Chapter 13. Representative documentation is required even if the representative is an attorney, family member or medical provider (See Special Condition 2, below). Representative documentation must be included in the case file submitted to MAXIMUS Federal Services for IRE Reconsideration. It is also the health plan s obligation to attempt to obtain the needed representative documentation. Plans must make, and document, their attempts to obtain this documentation. If a plan does not receive the representative documentation at the end of the appeal timeframe, PLUS EXTENSION, the plan must dismiss the request and issue a Notice of Dismissal of Appeal Request. Appellants have the right to request review of this dismissal. These dismissal reviews are discussed in more detail in Section 8 below. Please note, this means that plans must allow the full timeframe, plus any extensions allowable, for the requestor to submit the representative documentation. Plans should not issue a Notice of Dismissal of Appeal Request until the full timeframe, plus extension (if applicable), has expired. See Medicare Managed Care Manual Chapter 13, Special Condition 1: Enrollee Who Is Incapacitated or Incompetent If a member is incapacitated or incompetent and cannot sign an appointment of representative document, the Medicare Health Plan must apply state laws regarding legal representation of incapacitated or incompetent persons. If these laws require documentation, such documentation should be obtained by the Medicare Health Plan. The Medicare Health Plan's appeal staff should consult with the Medicare Health Plan's legal counsel to follow the applicable laws. MAXIMUS Federal Services does not require documentation in the IRE case file to substantiate that the Medicare Health Plan has properly applied State law. However, 17

19 the Medicare Managed Care Reconsideration Background Data Form does include a checkbox (under section 4-b) that must be selected in order for MAXIMUS Federal Services to accept the representative as valid. (See Appendix). The Appointment of Representative form can be found in Chapter 13 of the Medicare Managed Care Manual. Special Condition 2: A Physician May Initiate Expedited or Standard Pre-Service Reconsiderations without Appointment of Representation or Without Being the Provider-as Party. To determine if a requestor is a physician please refer to Social Security Act 1861(r). Any physician may make a reconsideration request on behalf of an enrollee to the Medicare Health Plan to initiate an expedited reconsideration. A treating physician may, upon providing notice to the enrollee, make a request for a standard pre-service reconsideration on the enrollee s behalf. These physicians are not required to obtain an appointment of representative document from the enrollee, nor are these physicians required to execute a waiver of enrollee liability. Consequently, no appointment of representative form is required in a case file submitted to MAXIMUS Federal Services. The Medicare Health Plan must, however, document the physician request in the case file. Please note, however, that appeals requested by non-physician providers require an Appointment of Representation. Federal regulations state that a physician must notify the enrollee of the standard service appeal request. For purposes of processing the appeal, it is the health plans responsibility to assess whether the enrollee has received proper notice. If the health plan processes the appeal request, MAXIMUS Federal Services assumes that the health plan has sufficient proof that the enrollee was properly noticed. Note that an appointment of representative requirement does apply to a provider who attempts to represent an enrollee in a standard claim reconsideration case Dismissal for lack of Proper Documentation If a reconsideration case file is submitted to MAXIMUS Federal Services that was initiated by a representative, MAXIMUS Federal Services will examine the file for compliance with the appointment requirements. MAXIMUS Federal Services will dismiss cases in which a required fully executed appointment of representative form is absent. (See Section 4.2.5) PROVIDER-AS-PARTY DOCUMENTATION Non-Contract Providers A non-contract provider may itself become the party to an appeal if that non-contract provider has executed a Waiver of Liability form. The purpose of this form is to ensure that the enrollee will not be held financially liable if the provider loses the appeal. The executed Waiver 18

20 of Liability document must be included in the case file submitted to MAXIMUS Federal Services. (See Section 4.2.5). Managed Care Manual Chapter 13, states that plans must make, and document, their attempts to obtain the Waiver of Liability. If the plan does not receive the Waiver of Liability by the conclusion of the appeal timeframe, the plan must dismiss the request and issue a Notice of Dismissal of Appeal Request. Non-Contract provider appellants have the right to request review of this dismissal. These dismissal reviews are discussed in more detail in Section 8 below. Please note that this means that plans should not issue a Notice of Dismissal of Appeal Request for lack of a Waiver of Liability until the appeal timeframe has concluded. A model Waiver of Liability form can be found in Chapter 13 of the Medicare Managed Care Manual Contract Providers Contract or "in-plan" providers of the Medicare Health Plan do not have rights to act as the party in an appeal. Payment disputes between a contract provider and the health plan, for which the enrollee has no liability, should be resolved through a forum outside of the Medicare managed care appeal process PROVIDER AS PERSON "SUPPORTING" THE ENROLLEE APPEAL Any person, including a provider, may "support" the enrollee appeal by providing written or oral testimony at the Medicare Health Plan level reconsideration or written testimony at the IRE level reconsideration. There is no requirement for execution of an appointment of representative or waiver of liability if the role of the person is simply providing testimony in support of an enrollee's appeal. The distinction between representation and support includes any of the following elements:(1) the person supporting the appeal has no standing to request the appeal proceeding, whereas the representative does, (2) the person supporting the appeal does not receive mandatory notices otherwise sent to the enrollee, whereas the representative does, (3) the person supporting the appeal cannot make decisions (for example, withdrawing the appeal), whereas the representative may do so, (4) the person supporting the appeal does not otherwise "manage" the enrollee's participation in the appeal, whereas the representative may. A physician may also, without being a representative, support a request for an appeal to be classified as an expedited reconsideration. The physician may make his/her statement of support in either written or oral form. The effect of such a statement is to mandate expedited status for the appeal if the physician's statement indicates that the application of a standard decision timeframe to the reconsideration could seriously jeopardize the life or health of the enrollee or the enrollee's ability to regain maximum function. 19

21 4.2.4 REPRESENTATIVE OF DECEASED ENROLLEE'S ESTATE The Medicare Health Plan has the responsibility to ensure that such representatives are legitimate. The Medicare Health Plan must indicate on the Reconsideration Background Data Form (by selecting the appropriate checkbox in section 4-b) if the appeal request initiated by an estate representative is valid. MAXIMUS Federal Services cannot rule on whether estate representation documentation is legitimate. The Medicare Health Plan should consult its legal advisor for assistance in determining the appropriate estate representative PROCESSING RECONSIDERATIONS WITH AN INVALID APPEAL REQUESTOR If the Medicare Health Plan receives a reconsideration request without the required executed representative or waiver of liability document (or in which the required document is incomplete or erroneous), the Medicare Health Plan level reconsideration review should not begin. However, the Medicare Health Plan must make reasonable attempts to inform the requestor of the inadequacy and obtain the representative or waiver of liability documents (See Chapter 13 of the Medicare Managed Care Manual). If the Medicare Health Plan does not get the appropriate documentation, then the plan must issue a Notice of Dismissal of Appeal Request per Chapter 13 of the Managed Care Manual. Appellants may request review of this dismissal under the process laid out in Section 8 of this manual. 4.3 NON-MEDICARE PLAN SERVICES The Medicare Managed Care appeal process applies only to basic and mandatory or optional supplemental benefits (42 CFR ). Some enrollees have additional benefits, outside the scope of the CMS approved benefit plan, provided separately by their employer or union. Denial of these benefits is not subject to Medicare reconsideration, and such cases should not be submitted to MAXIMUS Federal Services. However, if any portion of the denial overlaps Medicare basic benefits or the Medicare Health Plan mandatory or optional supplemental benefits, the case does qualify for Medicare reconsideration. Likewise, if the enrollee (or noncontract provider party) argues that the denied service should be covered under the Medicare benefits, as opposed to the employer provided benefits, the case should be reviewed as a Medicare reconsideration. 4.4 RECONSIDERATION PRIORITY There are three levels of reconsideration priority: (1) standard services request reconsideration; (2) standard claim payment reconsideration; and (3) expedited reconsideration. These three levels are defined in Section 2. Definitions. Refer also to 42 CFR Part 422 Subpart M for a complete definition and explanation of the differing requirements for these reconsiderations. The classification of a reconsideration as either an expedited or standard reconsideration is the responsibility of the Medicare Health Plan. The Medicare Health Plan should not ask 20

22 MAXIMUS Federal Services to determine whether a given request for expedited reconsideration should be granted. However, MAXIMUS Federal Services has the right to change a classification, if upon receipt, MAXIMUS Federal Services determines the case was misclassified. For example, if a Medicare Health Plan submits a standard claim payment case as expedited, MAXIMUS Federal Services may change the classification from expedited to standard claim. 4.5 MEDICARE HEALTH PLAN RESPONSIBILITY TO CONDUCT A FULL RECONSIDERATION Medicare Health Plans are required to conduct a thorough Medicare Health Plan level reconsideration, prior to submitting a case to MAXIMUS Federal Services for IRE level reconsideration. Consult 42 CFR and the CMS Medicare Managed Care Manual for a definition of the Medicare Health Plans obligations in conducting its reconsideration. In addition, the MAXIMUS Federal Services requirements and suggestions for IRE level case file preparation (See Section 5.3) will be difficult to meet if the Medicare Health Plan has not previously undertaken and documented a full Medicare Health Plan level reconsideration. MAXIMUS Federal Services may, at its discretion, utilize the "request for additional information" process (See Section 6.6), to direct Medicare Health Plans to remedy a case in which a complete Medicare Health Plan level reconsideration has not occurred or has not been documented. MAXIMUS Federal Services will notify CMS if a Medicare Health Plan displays a pattern of failure to complete and document a thorough Medicare Health Plan level reconsideration. 4.6 MEDICARE HEALTH PLAN RECONSIDERATION WITH INCOMPLETE EVIDENCE The Medicare Health Plan should gather all pertinent evidence or information before rendering its organization determination and completing the Medicare Health Plan level reconsideration. CMS policy dictates that a Medicare Health Plan should not automatically deny the enrollee's organization determination request due to a lack of documentation. Therefore, if the only available information is the enrollee's description, the Medicare Health Plan's decision must be based on that description. 1 Insufficient medical records are the primary example of incomplete evidence in Medicare Health Plan determinations. Medical necessity can almost never be ascertained by review of administrative (for example claim) data, but rather requires primary medical record documentation. As the CMS policies outlined above suggest, the burden of proof in a medical necessity denial is usually on the Medicare Health Plan, and absence of appropriate medical 1 The basis of the Medicare Appeals Process is the Constitutional protection of the enrollee's right to federal benefits to which that enrollee is entitled. The burden is therefore generally on the MA Organization to demonstrate that the enrollee is not entitled to the denied service or claim. Absence of evidence, and most notably relevant medical records, would generally undermine the MA Organizations arguments that it had demonstrated a legitimate process and basis for its denial. Possible exceptions would include non emergent or urgent enrollee "self referred" out-of plan services, without prior related health care access request to the MA Organization, where the enrollee and non-contracted provider will not cooperate in the provision of records. 21

23 records is likely to lead to the conclusion on IRE review that the Medicare Health Plan has not substantiated its denial. Certain CMS Medicare National Coverage Decisions (NCD) or Local Coverage Decisions (LCD) dictate that coverage or denial of an item or service be based upon specified medical evaluations and findings. For example, if the enrollee is requesting a wheelchair, the Medicare Health Plan should utilize reliable medical evidence to ascertain whether the enrollee is bed or chair confined. It is the Medicare Health Plans obligation to obtain such medical evidence before the IRE level reconsideration. Before submitting a case for reconsideration, the Medicare Health Plan should exhaust all reasonable efforts to obtain the required evidence and records. If the Medicare Health Plan is submitting a case file with incomplete evidence, the Medicare Health Plan should document these efforts in the case file. (See Section 5.3.4). 22

24 5. SUBMITTING RECONSIDERATION CASE FILES TO MAXIMUS FEDERAL SERVICES This Chapter defines the requirements for Medicare Health Plan preparation and submission of case files to MAXIMUS Federal Services for IRE level reconsideration under the following headings: 5.1 Cases That Must Be Submitted to MAXIMUS Federal Services for Reconsideration 5.2 Time Standards For Submission of Cases to MAXIMUS Federal Services 5.3 Preparation and Submission of the New Case File to MAXIMUS Federal Services 5.1 CASES THAT MUST BE SUBMITTED TO MAXIMUS FEDERAL SERVICES FOR RECONSIDERATION Federal Regulation 42 CFR and the CMS Medicare Managed Care Manual, Chapter 13 define cases that must be submitted for IRE reconsideration. The Medicare Health Plan must submit any case for which it is responsible for a Medicare Health Plan level reconsideration, unless the Medicare Health Plan has wholly reversed its initial adverse organization determination. Federal regulations define a case in which the Medicare Health Plan has failed to make a reconsideration determination by the applicable due date, as an affirmation of the adverse organization determination. Therefore, cases in which the Medicare Health Plan has not made a decision as of the expiration of the decision timeframe also must be submitted to MAXIMUS Federal Services. If the Medicare Health Plan subsequently obtains or develops additional information on any case (including an incomplete case), it must submit that information to MAXIMUS Federal Services. However, MAXIMUS Federal Services will not delay its review and makes no guarantee that such late, additional information can be taken into account prior to the MAXIMUS Federal Services determination. 5.2 TIME STANDARDS FOR SUBMISSION OF CASES TO MAXIMUS FEDERAL SERVICES The following sub-sections define time standards for case submission for each reconsideration priority (expedited, standard service and standard claim). Please note that all references to the "enrollee's request" for a reconsideration should be interpreted as a valid reconsideration request from any permissible appealing party, including representatives and noncontract providers. However, such a request does not become valid until and unless the documentation standards for parties and representatives are met (See Section 4.2) TIMELINESS OF SUBMISSION OF EXPEDITED RECONSIDERATIONS Federal regulations (42 CFR (d)) require the Medicare Health Plan to complete expedited cases within 72 hours of the enrollee (or enrollee's provider's) request, or sooner if the enrollee's health condition requires. The Medicare Health Plan may take an extension of up to 14 calendar days, if such extension is in the enrollee's interest. 23

25 For expedited cases only, the regulations (42 CFR (d)(5)) also define an additional interval for "submission" of the case file to MAXIMUS Federal Services. Submission is to occur within 24 hours of the Medicare Health Plan's completion of its reconsidered determination. The 24-hour period permitted for submission is thus in addition to the time permitted for the Medicare Health Plan reconsideration. The Medicare Health Plan must submit expedited reconsideration case files to MAXIMUS Federal Services via overnight/next day delivery rather than by standard mail. As a practical matter, MAXIMUS Federal Services assumes that Medicare Health Plan reconsideration decisions occur as of the close of the business day on which the decision is rendered. Therefore, the Medicare Health Plan meets the 24-hour standard if it submits the case to a commercial delivery service by that delivery vendor's close of business on the day after the Medicare Health Plan makes its reconsideration determination. 2 The case would then be delivered to MAXIMUS Federal Services on the next day that falls within the vendor's customary schedule. Exhibit 5-1: Expedited Case Submission Timetable, contains a table illustrating how these rules apply to submission of expedited cases. MAXIMUS Federal Services' offices are open to receive case file submissions Monday through Saturday. Day of Medicare Health Plan Determination Exhibit 5-1 EXPEDITED CASE SUBMISSION TIMETABLE Day of Medicare Health Plan Case Submission to Overnight Delivery Vendor Monday Tuesday Wednesday Tuesday Wednesday Thursday Wednesday Thursday Friday Thursday Friday Saturday* Friday Saturday* Monday Saturday Monday Tuesday Day of MAXIMUS Federal Services Receipt * Some delivery vendors require senders to specify "Saturday Delivery" on the envelope/package to be delivered. MAXIMUS Federal Services is open to receive cases on Saturday from 9 AM to 2 PM Eastern Time TIME STANDARD FOR SUBMISSION OF STANDARD SERVICE RECONSIDERATIONS Regulations at 42 CFR (a)(2) require the Medicare Health Plan to submit a standard service reconsideration to the MAXIMUS Federal Services: 2 As noted in Section 5.1, the failure of the MA Plan to make its reconsideration determination by the deadline is regarded as an adverse determination that triggers the requirement for case submission to MAXIMUS Federal Services 24